Hepatocellular carcinoma in cirrhosis: Incidence and risk factors

Emerging data indicate that the mortality rate of hepatocellular
carcinoma (HCC) associated with cirrhosis is rising
in some developed countries, whereas mortality from non-
HCC complications of cirrhosis is decreasing or is stable.
Cohort studies indicate that HCC is currently the major
cause of liver-related death in patients with compensated
cirrhosis. Hepatitis C virus (HCV) infection is associated
with the highest HCC incidence in persons with cirrhosis,
occurring twice as commonly in Japan than in the West
(5-year cumulative incidence, 30% and 17%, respectively),
followed by hereditary hemochromatosis (5-year cumulative
incidence, 21%). In hepatitis B virus (HBV)-related cirrhosis,
the 5-year cumulative HCC risk is 15% in high
endemic areas and 10% in the West. In the absence of
HCV and HBV infection, the HCC incidence is lower in
alcoholic cirrhotics (5-year cumulative risk, 8%) and subjects
with advanced biliary cirrhosis (5-year cumulative
risk, 4%). There are limited data on HCC risk in cirrhosis of
other causes. Older age, male sex, severity of compensated
cirrhosis at presentation, and sustained activity of
liver disease are important predictors of HCC, independent
of etiology of cirrhosis. In viral-related cirrhosis, HBV/HCV
and HBV/HDV coinfections increase the HCC risk (2- to
6-fold relative to each infection alone) as does alcohol
abuse (2- to 4-fold relative to alcohol abstinence). Sustained
reduction of HBV replication lowers the risk of HCC
in HBV-related cirrhosis. Further studies are needed to
investigate other viral factors (eg, HBV genotype/mutant,
occult HBV, HIV coinfection) and preventable or treatable
comorbidities (eg, obesity, diabetes) in the HCC risk in
cirrhosis.